A scoping review of lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI+) people’s health in India

Amid incremental progress in establishing an enabling legal and policy environment for lesbian, gay, bisexual, transgender and queer-identified people, and people with intersex variations (LGBTQI+) in India, evidence gaps on LGBTQI+ health are of increasing concern. To that end, we conducted a scoping review to map and synthesize the current evidence base, identify research gaps, and provide recommendations for future research. We conducted a scoping review using the Joanna Briggs Institute methodology. We systematically searched 14 databases to identify peer-reviewed journal articles published in English language between January 1, 2010 and November 20, 2021, that reported empirical qualitative, quantitative or mixed methods data on LGBTQI+ people’s health in India. Out of 3,003 results in total, we identified 177 eligible articles; 62% used quantitative, 31% qualitative, and 7% mixed methods. The majority (55%) focused on gay and other men who have sex with men (MSM), 16% transgender women, and 14% both of these populations; 4% focused on lesbian and bisexual women, and 2% on transmasculine people. Overall, studies reported high prevalence of HIV and sexually transmitted infections; multilevel risk factors for HIV; high levels of mental health burden linked to stigma, discrimination, and violence victimization; and non-availability of gender-affirmative medical care in government hospitals. Few longitudinal studies and intervention studies were identified. Findings suggest that LGBTQI+ health research in India needs to move beyond the predominant focus on HIV, and gay men/MSM and transgender women, to include mental health and non-communicable diseases, and individuals across the LGBTQI+ spectrum. Future research should build on largely descriptive studies to include explanatory and intervention studies, beyond urban to rural sites, and examine healthcare and service needs among LGBTQI+ people across the life course. Increased Indian government funding for LGBTQI+ health research, including dedicated support and training for early career researchers, is crucial to building a comprehensive and sustainable evidence base to inform targeted health policies and programs moving forward.


Introduction
The right to the highest attainable standard of health is both universal and fundamental in international law [1]. This is enshrined in Article 12 [2] of the Convention on Social, Economic, and Cultural Rights and underlies United Nations Sustainable Development Goal 3 (SDG-3), which promises "Health for All" by 2030 and that "no one will be left behind." This includes lesbian, gay, bisexual, transgender, queer identified, and people with intersex variations (LGBTQI+), who are entitled to the same standard of health as everyone else [3].
Despite the promise of the SDGs, evidence from across the globe suggests that LGBTQI + health consistently lags behind that of the general public. Systematic and scoping reviews on health and healthcare access among LGBTQI+ people in high-income countries have shown that these populations continue to face disproportionate physical and mental health burdens in contrast to heterosexual populations [4][5][6][7][8][9]. For example, global reviews and large-scale studies have documented high levels of problematic alcohol use [10], sexualized drug use [11], mental health problems [4,12], and high rates of HIV and other sexually transmitted infections (STIs) [13][14][15] among various LGBTQI+ subpopulations. Consistent with the minority stress model [16], many of these poor health outcomes are associated with societal stigma, discrimination, and violence, and systemic barriers in access to health services experienced by LGBTQI+ individuals [9,17,18].
Increasing recognition of health issues and disparities faced by LGBTQI+ people in the context of advances in LGBTQI+ rights movements globally have contributed to an evolving legal and policy environment that is becoming more supportive of LGBTQI+ rights, and more attuned to addressing LGBTQI+ health disparities and discrimination [19]. These advances in the recognition of LGBTQI+ rights have concomitantly contributed to increasing awareness of the need for research evidence to meaningfully implement this policy shift. Population-specific data are sorely needed to document gaps, disparities, and progress in LGBTQI+ health over time, as recognized by numerous bodies including the World Bank and UNDP; both have called for more attention and investment in research on LGBTQI+ health [20]. This trend is evident in India where the decriminalization of adult consensual same-sex relationships (2018) [21] and the enactment of the Transgender Persons Protection of Rights Act (2019) [22] have recently emerged in rapid succession. The latter act was designed, among other things, to support and promote the delivery of non-discriminatory and gender-affirmative health services to transgender people. Subsequently, India's Ministry of Social Justice and Empowerment's expert committee on issues related to transgender persons has called for research evidence to design interventions to improve the health of transgender people [23].
We are aware of no overview and thorough mapping of the evidence base on LGBTQI + health in India. A few published reviews of LGBTQI+ health in India have focused on specific topics, such as HIV research among MSM or mental health issues among LGBTQI+ individuals [24][25][26]. To address the fragmented nature of current research knowledge, we conducted a scoping review to synthesize the evidence on LGBTQI+ health in India. The aim of this review was to characterize the breadth of published research on LGBTQI+ health in India and identify gaps in the evidence base, to provide recommendations for future research, and to synthesize existing evidence to inform health policies and interventions to advance LGBTQI+ health.

Methods
We used the scoping review framework initially proposed by Arksey and O'Malley [27] and advanced by the Joanna Briggs Institute [28]. The key steps involved: (1) identifying the research questions; (2) identifying relevant studies; (3) study selection using a pre-defined set

Charting, collating and summarizing the results
The following data were extracted for analysis: year of publication, study location, sample size, study population, objectives, design, methodology (qualitative, quantitative or mixed methods) and key findings. We summarized the results using frequencies, and thematic analysis and synthesis [28]. Studies were grouped by key themes that emerged from the synthesis: prevalence of HIV and STIs, and risk factors; stigma, discrimination and violence, and health impact; access to health services; interventions to improve health outcomes among LGBTQI + populations; new HIV prevention technologies and their acceptability; and under-represented LGBTQI+ populations.

Study selection
The search strategy yielded 2,326 sources after removing duplicates. Screening of the titles and abstracts yielded 588 articles included in full-text review. Of these, 177 peer-reviewed articles met the a priori eligibility criteria and were included in the scoping review (Fig 1). We extracted study characteristics and key findings for the included articles (Table 1).
Overall, 77% of studies (n = 137/177) reported sources of funding support, and 12% (n = 21) reported not receiving any specific funding; 11% (n = 19) did not report sources of funding. Of those studies that reported a funding source, the majority (72%; n = 99/137) were foreign sources (largely from the U.S. National Institutes of Health [NIH] and the Bill and Melinda Gates Foundation); 12% (n = 17) were Indo-U.S. collaborative research projects funded jointly by the Indian Council of Medical Research (ICMR) and NIH. Twenty studies (15%) received primary funding from the government of India (Indian Council of Medical Research [ICMR] and the National AIDS Control Organization [NACO]) and other Indian institutions.

HIV/STI prevalence and risk factors
Thirty-seven percent (n = 65) of the articles focused on reporting STI/HIV prevalence estimates [30-47] and correlates of HIV-related risk behaviors [48-94] among MSM and TGW (Fig 4)

Stigma, discrimination, and violence, and health impacts
Over one-fourth of the articles (27%; n = 48) [95-142] reported on stigma, discrimination, violence, and their associations with physical and mental health. Among these, 16 articles focused on stigma-related aspects of LGBTQI+ health [96, 100-102, 109, 110, 112, 114, 119, 124-126,    139,140] indicated that stigma and discrimination contribute to depression and other negative mental health outcomes, such as suicidal ideation or attempts, among sexual and gender minorities. Two studies documented a high prevalence of mental health issues among MSM: depression (29% to 45%), anxiety (24% to 40%), suicidal ideation (45% to 53%), suicide attempts (23%), substance abuse (28%) including alcohol dependence (15% to 22%) [95,130]. Similarly, among TGW, high levels of depression (43%), problematic alcohol use (37%) [108], anxiety (39%), depression (21%), suicide risk (75.8%) [136] and violence (52%) [139] were reported. Three studies with MSM [99, 108, 109, 115] and one with MSM and TGW [108] reported psychosocial syndemics, that is, co-occurring psychosocial conditions such as problematic alcohol use and internalized homonegativity, and their synergistic impact on HIV risk. The COVID-19 pandemic was also addressed as exacerbating psychological distress among LGBTQI+ people [125,131].   [127]. Some MSM and TGW reported strategies to prevent violence, discrimination and psychological distress, which included bribing police, running away from unsafe places and persons, and negotiating condom use during forced sex encounters [109], hiding sexual identities [103], denial [123], and behavioral disengagement [141]. One study documented positive coping strategies among older transgender people, such as spirituality, hope, and acceptance of gender dissonance [125]. In a few studies, social support and resilient coping strategies were identified as predictors of HIV risk [108] or mediators and moderators of the effects of discrimination on HIV risk or depression [110]. A resilience-based psychosocial intervention that integrated counselling was found to be effective in reducing HIV risk among MSM, with self-esteem and depressive symptoms mediating this effect [133]. A community-based theatre intervention was identified as effective in improving positive attitudes and knowledge, and promoting acceptance and solidarity towards LGBTQI+ communities among young adult heterosexual audiences [134].
Of the ten articles on PrEP, eight examined acceptability or willingness to use PrEP among MSM and TGW; one explored the impact of prioritizing PrEP for MSM [184], and one compared the cost-effectiveness of offering PrEP to MSM with semiannual HIV testing as opposed to WHO-recommended 3-month testing [192]. Quantitative studies [176,177,[188][189][190]193] reported generally high willingness to use PrEP among MSM and TGW despite low levels of awareness. Qualitative studies [183,188] reported factors associated with PrEP uptake, including perceived effectiveness in serodiscordant relationships, providing protection in cases of forced sex encounters, ability to use covertly, ability to have sex without condoms, and anxiety-less sex; barriers included PrEP stigma, fear of disclosure to one's family or partners/ spouse, and being labelled as HIV-positive or 'promiscuous' by peers. A mathematical modelling study [184] in Bangalore reported that PrEP could prevent a substantial proportion of infections among MSM (27% of infections over 10 years, with 60% coverage and 50% adherence).
Of the 5 studies on future HIV vaccine acceptability [178][179][180][181]183], two [178,180] assessed willingness to participate (WTP) in hypothetical HIV vaccine trials among MSM; one [179] explored mental models of candidate HIV vaccines and clinical trials; and two [181,183] assessed frontline health service providers' perspectives on HIV vaccine trials and their likelihood of recommending HIV vaccines to MSM populations.

Underrepresented LGBTQI+ populations: Sexual minority women, transmasculine people and people with intersex variations
Sexual minority women. Seven studies (4%) focused on sexual minority women [194][195][196][197][198][199][200], while two additional studies [201,202] included sexual minority women as part of a larger sample. Among the seven studies, most focused on romantic relationships, such as communication and prioritization in relationships [199], difficulties in maintaining relationships [196], understanding of intimacy [197,198], and lack of legal recognition of same-gender romantic partnerships [198]. One study [197] used a collaborative ethnographic approach to capture the understanding of community and activism from the perspectives of "women loving women" which had indirect connections to mental health. Another study [200] documented resilience sources (for example, self-confidence, optimism) used by sexual minority women to cope with major stressors.
The sexual health of sexual minority women was explored in two studies [194,198]. One used photo-elicitation interviews and a survey to explore health behaviors and concerns [194], reporting that a majority of sexual minority women were not accessing preventive healthcare services: 36% reported having been screened for breast cancer and 14% for cervical cancer, and only 20% had ever been tested for STIs. The other study [198] reported lack of knowledge regarding STIs and difficulty in identifying LGBTQ-friendly service providers as major barriers to accessing preventive services.
Transmasculine people. Two studies (1%) [203,204] focused on transmasculine people's health: one [203] documented challenges in negotiating gender identity in various spaces, such as family, educational settings, workplace and neighborhoods; and one [204] reported that a substantially higher proportion of transmasculine persons (36.3%) attempted suicide when compared with transfeminine persons (24.7%).
People with intersex variations. Among the two studies (1%) [205,206] that focused on people with intersex variations, one [205] examined how healthcare professionals decide on gender assignment of intersex children, and the other study [206] documented the social stigma faced by people with intersex variations and their families. Findings from both of these studies highlighted that gender assignment decisions are influenced by sociocultural factors: parents of intersex children preferred a male gender assignment possibly because of the social advantages of growing up as a male in a patriarchal society.

Discussion
This scoping review of a decade of peer-reviewed research on the health of LGBTQI+ people in India demonstrates a trend of increased publications addressing the health of sexual and gender minorities; however, it also identifies substantial gaps in the research-in terms of focal populations, geographical coverage, health conditions, and methods. Overall, this review demonstrates a predominant research focus on HIV and HIV-related risk behaviors among MSM and TGW populations; of these studies, a small subset were intervention studies aiming to improve the health of MSM and TGW. Notably, this review reveals the near complete omission of research on the health of sexual minority women-less than 4% of the studies identified. And amid the substantial focus on transgender women, largely in the context of HIV, scant research addressed the health of transmasculine people.
From a methodological perspective, among the quantitative studies that constituted the majority of the research, most were cross-sectional and descriptive in nature; few studies used longitudinal designs or mixed methods approaches, with very few intervention trials. The inclusion of a substantial proportion of qualitative and mixed methods studies, however, suggests a strength in the potential for characterizing the lived experiences of diverse LGBTQI + people and experiences in the context of health disparities and challenges in healthcare access. Nevertheless, these too were dominated by a focus on MSM and TGW. A scoping review on LGBT inclusion in Thailand similarly reported substantial underrepresentation of lesbian and bisexual women, and transmasculine people, in the peer-reviewed literature [6].
The persistent and substantial gaps identified, even amid the overall increase in LGBTQI + health research in India, have important implications for future research and research funding, health policies and programs, and healthcare services and practices for LGBTQI+ populations. There is a clear and compelling need to expand the evidence base on LGBTQI+ health in India to the many health and mental health conditions beyond HIV, and to the health challenges experienced across the diversity of LGBTQI+ people.
Specific population gaps identified in health research among LGBTQI+ people in India indicate the need for greater attention to lesbian and bisexual women, including potential health and mental health disparities compared to cisgender heterosexual women. Additional focus on lesbian and bisexual women's experiences in access to and use of health services is sorely needed across an array of health conditions and healthcare settings, particularly given that studies reported their underutilization of routine preventive healthcare services. Reviews conducted on the health of sexual minority women in other countries arrived at similar conclusions [207,208]. Further gaps emerged in the dearth of research with transmasculine people [209], and more broadly in research on access to medical and surgical gender-affirmative care needs for trans people. Greater attention to studies of healthcare providers and healthcare settings, and on healthcare provider training, that aim to improve access to gender-affirmative clinical services are needed [210]. Finally, there is a wholesale lack of health research among people with intersex variations. Future studies should focus on general health profiles, experiences in access to healthcare, and impact of non-essential or 'corrective' surgeries on health and mental health outcomes among people with intersex variations [211,212].
Overall, the relatively small number of intervention studies were largely conducted with MSM in relation to HIV prevention. Nevertheless, while NACO supports several targeted interventions among MSM and TGW, with estimated programmatic coverage of nearly 88% to 95% of at-risk MSM and TGW [213], the lack of peer-reviewed publications on the effectiveness of such interventions limits their contribution to evidence-informed HIV prevention programs and policies in India. Although these interventions are primarily for programmatic purposes, the absence of published data represents a missed opportunity.
The stark lack of formal health outreach structures in India for lesbian and bisexual women, and for transmasculine people, makes it challenging to reach these populations through established organizational partners. Accordingly, greater involvement of a diversity of LGBTQI+ community-led groups in collaborative and participatory research studies is needed to expand opportunities to engage their inputs on research priorities, recruitment, and data collection methods, thereby also building their capacity in guiding and implementing research [214]. Such participatory mechanisms may be key to meaningful involvement of diverse and under-represented groups among LGBTQI+ communities and expanding relevant research evidence to advance their health. Strategic research funding mechanisms that target such underrepresented groups, as well as requiring community partnerships in certain health research streams, may be mechanisms to support such initiatives moving forward. For example, the U.S. NIH has established a sexual and gender minority research office, increased dedicated research funds, and released a five-year strategic plan to advance health research among sexual and gender minorities [215]. Similar steps need to be taken by the Indian Council of Medical Research, Department of Health Research. With just over one-fourth of the studies in this review funded fully or in part (in collaboration with NIH) by Indian government agencies, such as ICMR and NACO, there is a clear need to increase funding for LGBTQI+ health research by the Government of India.
This synthesis also highlights the connections between stigma, discrimination and violence, and the health issues faced by LGBTQI+ people. Several studies advance evidence on how discrimination and violence victimization contribute to psychosocial health problems and HIV risk among MSM and TGW [101,216]. Stigma and violence elimination programs, and interventions in multiple sectors (for example, healthcare, education, employment) and social campaigns to promote understanding and acceptance of LGBTQI+ people are needed. The lack of access to gender-affirmative hormone therapy and surgeries for trans people highlights the need to improve access to such services, especially in the context of the Transgender Persons (Protection of Rights) Act, 2019, of India. This act clearly places the responsibility on the Indian central government and state governments to provide medical gender-affirmative health services and health insurance for trans people [22].
Other research areas that require increased exploration include the role of family and peer support in LGBTQI+ mental health, interventions to increase support from families and communities, and programs to eliminate discrimination and promote acceptance in healthcare, educational and workplace settings [25]. Given the deleterious impacts of stigma and discrimination on mental health and access to care, and the protective effects of social support and resilience resources, studies that integrate an understanding of social-structural contexts that affect mental health are key to effective approaches to advancing LGBTQI+ health [26]. Expanding the evidence base on LGBTQI+ health will require additional investments by national and state health research funders, including targeted funding for non-HIV-specific LGBTQI+ health research in the academic sector and in government-funded and government-run health programs on HIV (National AIDS Control Program of NACO), sexual and reproductive health and mental health (under National Health Mission), and non-communicable diseases (for example, National Program for Prevention and Control of Cancers, Diabetes and Cardiovascular Diseases and Stroke).
Finally, few studies made explicit reference to theoretical frameworks (for example, syndemic theory [216], minority stress theory [96], and structural violence [217]), that guided study design, analysis or interpretation. For one, such theories can advance research and understanding of the needs of understudied populations, such as sexual minority women, with studies also benefitting from community-based participatory methodologies and partnerships [198,199]. The latter can advance application of theoretical frameworks that are sensitized to community-identified concerns, self-identifications, and priorities in Indian cultural contexts [199]. Several theoretical frameworks such as gender minority stress [218], gender affirmation [219] and intersectionality [220] that have been used productively in research among trans people in western countries, especially the U.S., appear not to be explicitly used in studies from India. Future research should include a focus on adapting existing frameworks to meaningfully address the Indian cultural context, as well as developing new indigenous frameworks for research with LGBTQI+ people in India. Future investigations should also ensure the inclusion of diverse subgroups of trans people-not solely gender binary, but also gender non-binary people-and portray local gender identity terms they use as well as indigenous constructions of gender identity, rather than defaulting to western terminologies, some of which do not translate well culturally or linguistically to the Indian LGBTQI+ experience [221].

Strengths and limitations
This scoping review should be understood in the context of study limitations. First, we limited searches to English-language texts and those included in major academic databases; however, we are not aware of Indian native language-based academic journals, given that academics and researchers largely publish in English. Second, we did not conduct quality assessments of individual studies as this is outside the purview of a scoping review; we aimed to map the field of available research, and research gaps, rather than answer a specific research question [28]. Third, we limited our review to peer-reviewed articles, for which we identified a substantial number of sources. Future scoping or systematic reviews should include grey literature from across India to broaden understanding of the landscape of research and gaps in regard to LGBTQI+ health; this is particularly the case given the concentration of studies identified among a minority of Indian states, and conducted almost exclusively in urban areas. Further, we did not include asexual-identified people in this review; future reviews should include this subpopulation to understand their health needs and healthcare experiences [222].

Conclusion
This scoping review identified key research gaps on LGBTQI+ health in India, with investigations largely limited to HIV-related issues, MSM and TGW populations, and urban study sites. This underscores the need for expanding health research in India to address the broad spectrum of LGBTQI+ people's lives, specifically in moving beyond HIV-focused research to address mental health and non-communicable diseases as well. Future research should address the extensive gender gap in LGBTQI+ health research in India by focusing on health needs and healthcare experiences of lesbian and bisexual women. The broader spectrum of transgender and gender nonbinary people also merits increased focus, including studies on health needs and gaps with transmasculine people.
Finally, it is crucial to include sexual orientation and gender identity in national health surveys and to provide disaggregated data among LGBTQI+ subpopulations so that extant inequalities between heterosexual and cisgender people, and within LGBTQI+ people, can be documented [223]. Large-scale government-supported national health surveys among LGBTQI+ people provide a unique opportunity to document and explain health inequalities, and to identify potential solutions [224]. Strategies to enhance health research among LGBTQI + people in India include developing a national LGBTQI+ health research agenda, providing dedicated LGBTQI+ health research funding from various government bodies, and investing in the training of researchers and new investigators to competently conduct LGBTQI+ health research. Additionally, investments in improving and sustaining the research and service provision capacities of community-based organizations are crucial as they already assume responsibility for serving a substantial number of LGBTQI+ people who are otherwise underserved by government-funded healthcare systems.